workbook 2 effective care and support - hse.ie · • governance arrangements are in place for the...

SPECIALISTPALLIATIVE

CAREMay 2014

Effective Care andSupportSupporting services to deliverquality healthcare

Effective Care and SupportQuality Assessment and Improvement: Specialist Palliative Care Services, May 2014

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Welcome to the Effective Care and Support Quality Assessment and Improvement Workbook. This workbook will supportassessment teams in preparing for assessment against Theme 1 of the National Standards for Safer Better Healthcare. Teamscan use this workbook to familiarise themselves with the assessment process prior to undertaking assessment using theweb enabled Quality Assessment and Improvement Tool.

There are 8 Standards and 10 Essential Elements of Quality under Theme 1. The Essential Elements are specific, tangibletranslations of the National Standards. They represent those key aspects of quality you would expect to see within a servicethat is delivering safe, sustainable, high quality care. There are four Levels of Quality for each Essential Element. These Levelsbuild on each other and allow services to objectively assess the Level of Quality and maturity that most accurately reflectstheir service. The contents within each Level are guiding prompts as to what a service should be achieving for that Level andare not specific criteria that must be in place. Progress through these ascending Levels of Quality assumes that the mainaspects of quality within the previous Level have been achieved before you move to the next Level.

Given that the National Standards for Safer Better Healthcare are relatively new to the healthcare system, it is recognisedthat implementing these standards may be challenging and require significant effort by services. Therefore a guiding principleof the assessment is to create a process of continuous quality improvement progressing towards full implementation. Insome cases services may not have progressed as far along their quality journey compared to other services. This may resultin services determining that for some Essential Elements and Standards they have not yet achieved ‘Emerging Improvement’,the first Level of Quality. In this instance services should not select a Level of Quality for these Essential Elements; insteadthey should consider outlining in the Additional Information section the necessary actions they need to implement to achieve‘Emerging Improvement’ and higher Levels of Quality.

A list of examples of evidence is provided to support you in verifying your selected Level of Quality for each Essential Element.This list is intended as a guide and services can include additional evidence that better supports their selected level.

Similarly services may wish to consider the following bullets to guide them in providing additional information to supporttheir assessment.

• Structures and processes in place and how they have been evaluated.• Strategies and plans developed and implemented.• Risks identified and improvement actions taken.• Challenges to progressing to higher levels of quality.• Outcomes achieved and examples of good practice.

Introduction


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Levelsof

Quality

Emerging Improvement (EI)

Continuous Improvement(CI)

Sustained Improvement(SI)

Excellence (E)

There is progress with a strong recognition of the needto further develop and improve existing governingstructures and processes.

There is significant progress in the development,implementation and monitoring of improved qualitysystems.

Well established quality systems are evaluated,consistently achieve quality outcomes and supportsustainable good practice.

The service is an innovative leader in consistentlydelivering good service user experience and excellentquality care.

The key output of this assessment is the development of improvement actions which will support your service in implementingthe National Standards for Person Centred Care and Support and improving the quality of your service.

An overview of the steps within the assessment process for the National Standards for Safer Better Healthcare is illustratedin Figure 1.

Figure 1 Overview of Assessment Process


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8 Themes

View Standards under selectedTheme

View Essential Element(s) ofQuality

Select Level of Quality forEssential Element

Select and provide additionalevidence that supports theselected Level of Quality

Provide additional information forthe Essential Element andselected Level of Quality

Agree Improvement Actions

Continue assessment against nextEssential Element/Standard/Theme

Select a Theme tocommence assessment

Select a Standard toassess against

Select an EssentialElement to assess

against

Quality ImprovementPlan


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2. EFFECTIVE CARE AND SUPPORT

WHAT A SERVICE USER CAN EXPECT OREXPERIENCE WHEN A SPECIALISTPALLIATIVE CARE SERVICE IS MEETINGTHIS STANDARD.

SPC provided will be based on the bestavailable evidence to maximise your healthbenefit.

Your plan of care will be based on yourassessed and ongoing palliative care needs.Palliative care received will be timely andregularly reviewed and you will be involvedin all decisions about your care.

Your palliative care will be safely andeffectively co-ordinated within and betweenservices at all times and you and yourfamily will receive appropriate information.

You will have an identified lead healthcareprofessional accountable and responsiblefor your care at all times.

The SPC professional caring for you willhave timely access to all relevantinformation provided to support decisionmaking.

You will be provided with clear informationabout the palliative care service and you willbe informed of any changes to the service.

You will receive palliative care in healthcarefacilities which are safe, effectivelymanaged and protect your dignity andprivacy.

Your SPC service will monitor, evaluate andcontinuously improve the quality ofpalliative care provided and seek yourfeedback to support this improvement.

ESSENTIAL ELEMENTS

ImplementingBest Available Evidence

(A) ComprehensiveDocumentedAssessment of Need

(B) Recognising andResponding to theImminently DyingPerson

(C) The Provision ofSpecialist PalliativeCare

Safe and Co-ordinated Transfer of Care

Lead Healthcare Professional

Information Enabling Clinical Decision Making

Service Delivery Model

A Physical Environment that Protects Health andWelfare

Monitoring andImproving Healthcare Quality

STANDARD

STANDARD 2.1Healthcare reflects national andinternational evidence of what is known toachieve best outcomes for service users.

STANDARD 2.2 Care is planned and delivered to meet theindividual service user’s initial and ongoingassessed care needs, while taking accountof the needs of other service users.

STANDARD 2.3 Service users receive integrated care whichis co-ordinated effectively within andbetween services.

STANDARD 2.4An identified healthcare professional hasoverall responsibility and accountability fora service user’s care during an episode ofcare.

STANDARD 2.5 All information necessary to support theprovision of effective care, includinginformation provided by the service user, isavailable at the point of clinical decisionmaking.

STANDARD 2.6Care is provided through a model of servicedesigned to deliver high quality, safe andreliable healthcare

STANDARD 2.7 Healthcare is provided in a physicalenvironment which supports the delivery ofhigh quality, safe, reliable care and protectsthe health and welfare of service users.

STANDARD 2.8 The effectiveness of healthcare issystematically monitored, evaluated andcontinuously improved.


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Essential Element: Implementing Best Available Evidence

Specialist Palliative Care (SPC) is based on best available evidence and the knowledge and experience of service users andstaff.

STANDARD 2.1

Healthcare reflects national and international evidence of what is known to achievebest outcomes for service users

GUIDING PROMPTS

• A range of strategies to support evidence based practice are utilised by theorganisation e.g. decision-support systems and other reminders, audit andfeedback, production of educational materials, use of interactive educationalmeetings.

• Policies and procedures are reviewed for alignment with evidence-basedpractice and strategies are developed for updating those that are not.

• Staff are supported in accessing evidenced based information.• The potential for innovation and calculated risk taking is acknowledged and

promoted as a necessary process when developing evidence and applying topractice.

• Governance arrangements are in place for the support of evidence basedpractice e.g. policies, procedures, protocols, guidelines (PPPGs) and carepathways.

• There is an agreed plan supporting implementation of the National ClinicalProgramme for Palliative Care initiatives.

• The experiences of service users, families and staff are used to inform theongoing implementation and adaptation of evidence-based practices toeffectively meet the needs of service users and their families.

• Baselines of performance are measured as a snapshot of how the organizationis currently performing and performance data is used as a learning/qualityimprovement tool e.g. 1. Are we doing evidence-based work? 2. Are we doing it well? and 3. Is it leading to desired outcomes?

• Recommendations from internal and external audit reports are implemented. • Relevant regional and national targets for measures of healthcare delivery are

regularly achieved.• Evaluation of implementation of evidence based practice strategies is

undertaken.

• Service benchmarks performance and shares learning with other serviceproviders.

• Organisations do not only replicate what has been done elsewhere, they useresearch findings to develop innovative approaches to improved healthcaredelivery and share the learning with other organisations.

LEVEL OFQUALITY

EmergingImprovement(EI)

ContinuousImprovement (CI)

SustainedImprovement (SI)

Excellence(E)

SELECT

Examples

• Opportunities and resources are provided for SPC staff to access best available information. • Attendance at education/development events.• Develop a plan and monitoring system for the implementation of the National Clinical Programme for Palliative Care.• Arrangements to support and manage policy development and review. • Clinical Care Pathways established, implemented and evaluated.• Risk assessments on the implementation of National Clinical Programme for Palliative Care, guidelines, policies and care

pathways. • Governance and shared decision making structures explicitly support innovation and calculated risk-taking as part of a

learning culture. Note Calculated risk-taking does not over-ride professional and organisational responsibility to do noharm.

• Implementation of clinical audit programme.

Evidence to verify selected level of quality


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Addtional information


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Essential Element (A): Comprehensive Documented Assessment of Need

SPC provision is planned, agreed and documented to reflect individual’s initial and ongoing assessed needs.

STANDARD 2.2

Care provision is planned and delivered to meet the individual service user’s initialand ongoing assessed healthcare needs, while taking account of the needs of otherservice users

GUIDING PROMPTS

• A comprehensive and timely interdisciplinary assessment of the needs of serviceuser and family forms the basis of the plan of care.

• A unified approach to assessing and recording the needs of service users isadopted.

• The individualised care plan is based on the identified and expressedpreferences, values, goals, and needs of the service user and family and isdeveloped with support for decision-making.

• Staff working in SPC services are provided with education on developingindividualised care plans and accurate documentation of information.

• Changes to the individualised care plan are based on the evolving needs andpreferences of the service user and family over time and recognise the complex,competing, and shifting priorities in goals of care.

• Service users are offered education opportunities and are supported to developself-management skills (e.g. equipping service users and families to managemedical and care aspects of illness, managing life roles and promotingadaptation to the changing dynamics brought on by illness and its progression).

• SPC care plans are audited to ensure completeness, accuracy and timely reviewof assessments.

• Service user assessed palliative care needs that cannot be met within the scopeof the service are appropriately recognised and managed.

• Family is offered education and supported to provide safe and appropriatecomfort measures to the individual where desired and appropriate.

• There is service user involvement in evaluating the quality of SPC assessmentsand care plans.

• Circumstances and structure, process and outcomes of SPC emergencyassistance are regularly reviewed and staff receive feedback on performance.

• Family is provided with backup resources in response to urgent needs.• The service learns from national and international incidents and quality

improvement initiatives relating to care planning and implements improvementslocally.

• The organisation seeks opportunities to lead and support quality improvementinitiatives relating to care planning at regional and national levels.

LEVEL OFQUALITY




Excellence(E)

SELECT


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Examples

• Documentation of interdisciplinary assessments.• Treatment of distressing symptoms and side effects incorporates pharmacological and non pharmacological therapies.• Evidence of service user/ family/ caregiver education opportunities and promotion of self-management• Compliance with Healthcare Records Management Standards e.g. content of healthcare record.• Staff attend education/development/training for improving SPC assessments.• Incident analysis and improvement plans.• Governance reports from audits of healthcare records management • Service user and family feedback informs improvement plans.


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Essential Element (B): Recognising and Responding to the Imminently Dying Person

Service users whose condition is deteriorating are recognised and an appropriate timely response is taken.

STANDARD 2.2

Care is planned and delivered to meet the individual service user’s initial andongoing healthcare needs, while taking account of the needs of other service users

GUIDING PROMPTS

• The care plan is revised to meet the unique needs of the service user and familyat this phase of the illness.

• Service user and family wishes regarding care setting for death aredocumented. Any inability to meet these needs and preferences is reviewed andaddressed, as far as is possible, by the team.

• The service facilitates religious, spiritual or cultural rituals or practices asdesired by service user/ family at and after the time of death.

• Post-death care is provided in a respectful manner and in accordance withreligious and cultural values and legal requirements.

• A bereavement plan is developed for service users’ families that is based onsocial, cultural and spiritual grief assessment.

• Service users/ families are informed of signs and symptoms of deteriorationrelevant to their condition (where appropriate and desired) and how to raiseconcerns.

• The family is offered opportunities for education regarding the signs andsymptoms of approaching death in a developmentally, culturally, and age-appropriate manner.

• Arrangements are in place which provides families and carers with appropriate,relevant and accessible information and training to enable them to carry outtheir caring responsibilities.

• Improvements to the care of the dying person are influenced by feedback fromstaff and audits.

• Systems for responding to the imminently dying person are evaluated andimprovements implemented.

• Service disseminates the learning from incidents involving failure to recogniseand respond to clinical deterioration.

• The service benchmarks its performance with other providers. • The service learns from national and international incidents and quality

improvement initiatives and implements improvements locally. • The service actively seeks new knowledge and innovations in improving the care

of the dying person and creates appropriate change.

LEVEL OFQUALITY




Excellence(E)

SELECT


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Examples

• Staff attend development and education opportunities provided.• Analysis of incidents relating to failure to identify/ respond to palliative care needs and implementation of improvement

plans. • Evaluation of arrangements to escalate care and call for emergency assistance. • Evaluation of service user and family information. • Audit of performance against outcome measures and implementation of improvement plans.• Implementation of learning from national and international incidents.• A culture of openness to innovation and calculated risk taking is encouraged, developed and evaluated.


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Essential Element (C): The Provision of Specialist Palliative Care

Service users receive palliative care that is integrated, organised and appropriate to their needs and wishes.

STANDARD 2.2

Care is planned and delivered to meet the individual service user’s initial andongoing assessed healthcare needs, while taking account of the needs of otherservice users

GUIDING PROMPTS

• Service users' and families’ understanding of disease, and treatments isassessed and documented.

• Regular, ongoing assessment of physical, psychological, social andspiritual distress and functional impairment are documented through asystematic process.

• The response to distress is prompt and tracked through documentation inthe person’s record.

• The outcome of management is the safe and timely reduction of distresslevels, to a level that is acceptable to the person (or the family if the personis unable to report distress).

• Treatment alternatives are clearly documented and communicated andpermit the service user and family to make informed choices.

• The provision of care is reviewed and audited with improvement plansimplemented.

• Feedback and incidents are analysed and addressed to improve the qualityof care.

• Palliative care education and development programmes support clinicaland non clinical staff.

• Service develops and monitors performance measures relating to theprovision of palliative care.

• Delivery of palliative care is evaluated which includes feedback fromfamilies/carers.

• There is implementation and monitoring of external reportrecommendations.

• Learning is shared from audits, report recommendations and performancereports throughout the service.

• There is collaboration and partnerships between hospital and communityservices to respond to the needs of individuals who have a life limitingillness.

• Benchmarking with other service providers is undertaken to support theimplementation of improved practice.

LEVEL OFQUALITY




Excellence (E)

SELECT


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Examples

• Implementation of recommendations from National Advisory Committee on Palliative Care (2001)• Referrals to healthcare professionals with specialised skills in symptom management are made when appropriate (e.g

radiation therapists, anaesthesia pain management specialists, orthopaedic services).• Implementation of outputs from the National Clinical Programme for Palliative Care.• Use of approptiate and relevant palliative care resources e.g. spiral symbol, information leaflets etc.• Evidence of review of the design and dignity within the physical environment. • Staff attend palliative care education and are offered development opportunities.• Implementation of improvement plans from local and national audits.


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Essential Element: Safe and Co-ordinated Transfer of Care

The co-ordination and continuity of care between and within interdisciplinary teams and other service providers is effectivelymanaged.

STANDARD 2.3

Service users receive integrated care which is co-ordinated effectively within andbetween services

GUIDING PROMPTS

• Staff are provided with education and development opportunities to support theco-ordination of care within and between services with a strong focus oneffective communication.

• SPC staff understand and show respect for the roles of other services in theprovision of care.

• Services implement processes to ensure effective inter-professionalcommunication within teams and between them and other service providerswith whom the service user has contact.

• The outcome of consultations in which key information is discussed is recordedin service user’s notes and communicated to other professionals involved intheir care.

• Service users and other service providers e.g. primary care and hospital teamsare informed in advance of any plans to transfer or share any aspects of theircare.

• Mechanisms are developed to promote continuity of care but as yet are notconsistent across the organisation,

• Review and audits of policies, protocols and national guidance relating tocoordination and integration of care are undertaken.

• Findings from relevant audits and incident analysis inform multidisciplinaryteam development and education.

• The findings from service user/familiy experience surveys are monitored andinform quality improvement plans.

• Organisations engage in the provision of an integrated model of care.

• Organisation leaders strongly support integration as practice model withexpected change in service delivery, and resources provided for development.

• Integrated care and all components embraced by all providers in care systemand there is active involvement in practice change.

• Sharing of information systems with other service providers contributes toseamless service provision.

LEVEL OFQUALITY




Excellence(E)

SELECT


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Examples

• Implementation of HSE Code of Practice for integrated discharge planning including the Rapid Discharge PlanningPathway.

• Implementation of Clinical Handover policy. • Audit of compliance with PPPGs relating to coordination and integration of care.• National referral pathways. • Audit of national referral pathways and protocols e.g. PC referral form.• Review of incidents and implementation of improvement plans.• Implementation of recommendations from investigations.• Review of referral and transfer protocols and policies. • Referring physicians and healthcare providers are routinely informed about the availability and benefits of hospice and

other community resources for care for their service users and families as appropriate and indicated. • Policies for formal written and verbal communication about all domains in the plan of care are established between SPC

services, and other major healthcare providers involved in the care of service users.• Policies enable timely and effective sharing of information among teams while safeguarding privacy.• Where possible SPC staff routinely participate in each other’s team meetings to promote regular professional

communication, collaboration, and an integrated plan of care on behalf of service users and families.• SPC service and other major community providers, seeks opportunities to collaborate and work in partnership to promote

increased access to quality palliative care across the continuum.• There is a focus on developing person-centred workplaces using a team approach.


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Essential Element: Lead Healthcare Professional

Service users and families know the identified lead healthcare professional that is responsible and accountable for their care.

STANDARD 2.4

An identified lead healthcare professional has overall responsibility andaccountability for a service user’s care during an episode of care

GUIDING PROMPTS

• There is an identified lead healthcare professional responsible and accountablefor the care of each person whilst receiving palliative care.

• Arrangements support the formal handover of care between healthcareprofessionals.

• Information is provided to service users and families on how to contact leadhealthcare professional.

• Clear documentation of the identified lead healthcare professional and anychanges in this lead role.

• Effectiveness of clinical handover is documented, monitored, reported andimprovement plans implemented.

• Analysis and trending of incidents pertaining to clinical handover informimprovement plans and evaluations.

• Service learns from local events and shares learning within the service. • Feedback from service users and families also informs improvement plan and

evaluations.

• Service learns from national and international experience and reflects thislearning in its practice.

LEVEL OFQUALITY




Excellence(E)

SELECT


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Examples

• Audit of healthcare records to determine documentation of lead health care professional.• Implementation and evaluation of performance metrics• Implementation and evaluation of clinical handover policy.• Implementation of HSE national guidance to support integrated care and discharge including Rapid Discharge Guideline.• Service user and family are provided with contact details of lead healthcare professional. • Analysis and trending of incidents and implementation of improvement plans.• Evaluation of service user and family feedback and implementation of improvement plans.• Implementation of learning from national and international experience.


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Essential Element: Information Enabling Clinical Decision Making

Complete and accurate information is available and accessible to healthcare professionals to support them in making effectiveclinical decisions.

STANDARD 2.5

All information necessary to support the provision of effective care, includinginformation provided by the service user and family is available at the point ofclinical decision making

GUIDING PROMPTS

• Evidence-based clinical content is readily available to staff e.g. guidelines,literature.

• Protocols are developed and readily available to staff.• Arrangements support the sharing of service user information internally and

externally in a confidential manner. • Staff receive opportunities for education and training on their obligations of

complying with legislation when sharing information.

• Information systems that support palliative care provision are in place e.g.assessment instruments, flow sheets, drug interaction databases.

• Review and audit of access to, and utilisation of, necessary healthcareinformation is undertaken.

• Improvement plans are implemented to improve access to, and utilisation of,necessary healthcare information.

• Incidents are analysed and trended and improvement plans implemented.

• Interdisciplinary care plans, evidence-based clinical practice guidelines andintegrated documentation is in place.

• Evaluation and inclusion of staff feedback informs improvements. • Sustainable achievement of relevant performance measures.• Service learns from incidents and shares learning within the service.

• Clinical decision support is embedded within electronic health records.• Drug-decision support and e-prescribing is in place. • E-learning platforms are in place supported by a performance and learning

management system.

LEVEL OFQUALITY




Excellence(E)

SELECT


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Examples

• Audit of implementation of national standards for health care records management and storage.• Review of access to healthcare information.• Implementation of improvement plans.• Staff attendance at education, development and training.• Minutes of MDT meetings. • Evidence of compliance with legislation e.g. Data Protection Act. • Analysis and trending of incidents. • Evidence of FOI compliance.• Evidence of compliance with information governance e.g. ‘What You Should Know About Information Governance, A

Guide for Health and Social Care Staff’ (HIQA); Guidance on Information Governance for Health and Social Care Servicesin Ireland’ (HIQA, 2012)

• Management of information for secondary users i.e. next of kin, bereaved family members.• Existence of order sets, care plans, evidence-based clinical and drug reference and decision-support tools.• Receipt of health alerts from public agencies.• Integrated documentation.


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Essential Element: Service Delivery Model

Evidence based service delivery models underpin service delivery.

STANDARD 2.6

Care is provided through a model of service designed to deliver high quality, safeand reliable healthcare

GUIDING PROMPTS

• Governance arrangements support implementation of agreed service deliverymodel.

• Statement of purpose reflects service delivery model.• Staff receive regular information regarding the agreed service delivery model.• Service implements relevant National Clinical Programmes.

• Review of governance arrangements to ensure safe transfer of care when carecan not be provided within current service delivery model.

• Governing committees receive reports on implementation of service deliverymodel.

• Review of the implementation of the National Clinical Programmes informimprovement plans.

• Performance measures are monitored and reported. • Staff receive opportunities for education, development and training to support

implementation of service delivery model.

• Evaluations of the effectiveness of service delivery model are undertakenincluding assessment of case mix and case load of service users.

• Service uses the learning from incidents, service user and family, staff feedbackand external report recommendations to change model.

• Performance against process and outcome measures also informs changes toservice delivery model.

• The service contributes to regional and national agendas to improve theevidence base for specialist palliative care.

• Service takes account of national and international evidence of service modelsand care pathways.

• The organisation seeks opportunities to lead and support quality improvementinitiatives relating to models of service delivery at regional and national levels.

• Service receives recognition for innovative effective changes to service deliverymodel.

LEVEL OFQUALITY




Excellence(E)

SELECT


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Examples

• Opportunities for SPC staff to access information relevant to model of care e.g. Report of the National Advisory Committeeon Palliative Care (2001)

• Plan to support implementation of service delivery model • Attendance at relevant staff education, development and training. • Review of case mix and case load of service users to inform changes in model i.e. Minimum Data Set (MDS) in Palliative

Care.• Review of effectiveness of implementation of National Clinical Programmes. • Audit of compliance with legislation e.g. European Working Time Directive (EWTD).• Review of staff, service user and family feedback inform improvements.• Publicly available statement of purpose.• Reporting of performance measures.


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Essential Element: A Physical Environment that Protects Health and Welfare

The service has appropriate arrangements in place to ensure compliance with Health and Safety Legislation and NationalStandards.

STANDARD 2.7

Healthcare is provided in a physical environment which supports the delivery ofhigh quality, safe, reliable care and protects the health and welfare of service usersand their families

GUIDING PROMPTS

• Service is fully aware of its obligations to comply with Health and Safetylegislation and relevant National Standards.

• Site specific Safety Statement includes all relevant risk assessments undertakento address all foreseeable risks to the health and safety of service users, familiesand staff.

• All staff receive appropriate education and training opportunities in line withstatutory and mandatory requirements and attendance is recorded andmonitored.

• Action plans are implemented to manage identified risks to service users,families and staff.

• Health and Safety committee review and monitor action plans and advise onescalation of risk to the risk register.

• Service carries out a Health and Safety audit in accordance with the Health andSafety Authority’s audit tool on an annual basis.

• All education and development programmes are reviewed and amended toreflect changes in legislation.

• The setting addresses the unique care needs of children as service users, familymembers, or visitors.

• Staff acknowledge personal responsibility in contributing to a conducivephysical environment e.g. staff generated noise reduction; respect for serviceusers personal space and need for privacy; innovative ways to further createsuitable therapeutic environments.

• Audit results and corrective actions are implemented within agreed timeframesand are monitored by the Health and Safety Committee.

• Plans to address non compliances are prioritised and progress reported to inline with governance arrangements.

• Governing committees receive assurance reports to demonstraterecommendations from the Health and Safety audit have been implementedwithin the agreed timeframes.

• Performance against the Health and Safety Authority’s audit tool is consistentlydemonstrating compliance with legislation.

• Governing committee has adopted innovative approaches to facilitating staff inmaintaining knowledge of all relevant legislation.

LEVEL OFQUALITY




Excellence(E)

SELECT


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Examples

• Audit of compliance with Health and Safety Legislation.• Environmental risk assessments. • External risk assessments, resultant improvement plans and report recommendations.• Environmental improvement plans uses Design Guidelines for Specialist Palliative Care Settings (DoH&C, 2005).• Policies to support safe facilities and environment.• Audit of compliance with policies. • Staff education, development and training opportunities. • Service user and family involvement and evidence of staff and service user feedback.• Review principles of the National Healthcare Charter.• Responsibility for the physical environment is shared by all staff.


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Essential Element: Monitoring and Improving Healthcare Quality

Healthcare quality is regularly monitored and reported to improve the quality of care provided.

STANDARD 2.8

The effectiveness of health care is systematically monitored, evaluated andcontinuously improved

GUIDING PROMPTS

• Governance arrangements support the monitoring and reporting of healthcarequality.

• There are structured approaches to monitoring and reporting of national andlocally agreed quality and performance indicators e.g. Compstat and QualityProfiles.

• Staff are provided with opportunities for relevant education, development andtraining on measuring and monitoring quality of healthcare.

• Performance reports, quality profiles and audit findings are reported in line withgoverning arrangements.

• Improvement plans are developed in response to quality and performanceinformation.

• Indicators for healthcare quality include service user, family and staff experience. • Service participates in national audits and quality assurance programmes which

inform quality improvement plans. • Staff receive regular updates on quality of care findings provided by the service.

• Service evaluates current sources of information to further develop its QualityProfile.

• A review of national and international indicators is undertaken to inform localadaptation.

• Service benchmarks performance with other providers and demonstratesconsistent performance.

• An annual report is publicly reported which includes the services Quality Profile.

• Learning from different measuring and monitoring approaches is shared withother service providers.

• Service receives recognition for innovative approaches.

LEVEL OFQUALITY




Excellence(E)

SELECT


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Examples

• Evidence of implementation of the Organisation's Quality Profile.• Monitoring and reporting of national quality audits. • Implementation of local audit programmes.• Implementation and evaluation of improvement plans.• Results of benchmarking informing improvement plan.• Annual reports on quality of care provided. • Attendance at staff education, development and training.• Involvement in National Quality Assurance and implementation of recommendations.


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Improvement Actions for Theme 2: Effective Care and Support


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Standard Essential Improvement Action Responsible Due DateElement Team Member

workbook 2 effective care and support - hse.ie · • governance arrangements are in place for the...

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